Sex between men happens in every part of the world. Some men who have sex with men (MSM) label themselves as gay, others as bisexual, while a large number – particularly outside western countries – simply see themselves as ‘normal’ males who just happen to have sex with other men.
"I’m not gay… I just like having sex with men." - Noun, Cambodia 1
In the context of the global AIDS epidemic, sex between men is significant because it involves anal sex – a practice that, when no protection is used, carries a higher risk of HIV transmission than unprotected vaginal sex. Historically, AIDS was first discovered among self-identified young gay men in the USA, and throughout the course of the global epidemic, consistently high levels of HIV infection have been found among MSM in many countries.
Organisations representing MSM have also played an active and outspoken role in the response to AIDS. In the USA and the UK for example, gay men’s organisations have raised a great deal of awareness about HIV and AIDS. These groups continue to provide many services to both prevent people becoming infected with HIV, and to help those who are HIV-positive. Another example is Brazil, where groups of gay men exerted a lot of pressure on the government to protect the rights of HIV-positive people in the early years of the nation’s AIDS epidemic.
In many countries however, MSM are not so visible. Sex between men is stigmatised, officially denied and criminalised in various parts of the world. This adds to the vulnerability of MSM, making it difficult to monitor them, and making it near impossible to carry out relevant HIV prevention campaigns in some countries. In places where homosexuality is not tolerated, MSM often hide their same-sex relations from their friends and families to avoid persecution. Many have wives, or have sex with women as well as men, and this means that they may transmit HIV to their female partners if they become infected. The significant impact that HIV is having on MSM is therefore not an isolated problem, but one that is very much linked to countries’ wider HIV epidemics.
MSM and HIV – the global picture
Worldwide, it’s estimated that sex between men accounts for between 5 and 10% of HIV infections. The situation varies between countries however, and in much of the developed world – including the USA, Canada, the UK, Australia and New Zealand – more people have become infected with HIV through male-male sex than through any other transmission route.
Sex between men is also a prominent feature in the spread of HIV in less developed regions. In Latin America, sex between men accounted for a quarter of new HIV infections during 2005. In Asia, HIV prevalence levels among MSM have reached as high as 18% in Andhra Pradesh, India, 15% in Phnom Penh, Cambodia, and 28% in Bangkok, Thailand – figures that are many times higher than those found among these countries’ overall populations. In Japan, around 60% of HIV-positive people are MSM.2 In Africa – a region not commonly associated with male-male HIV-transmission – there’s evidence from some countries that transmission through this route is a significant problem. In Senegal for instance, one study recorded that 22% of MSM were living with HIV.3
Although statistics like these give an idea of the impact that AIDS is having on MSM, data is still extremely scarce in many countries. This is largely due to the fact that MSM often have no separate social identity, and are simply counted as part of the general population. It is also due to the reluctance of governments to acknowledge MSM, and to monitor this group.
Another factor blurring statistics is that it’s not always possible to tell how a man became infected. If he is having sex with women as well, he may well report that HIV was transmitted to him from a woman (or even if he is only having sex with other men, he may lie because of stigma). This can distort figures.
From the information that is available, it’s clear that HIV is a significant burden to communities of MSM around the world. But why is this the case? To answer this question, we need to look at the factors that put MSM at risk.
What makes MSM vulnerable to HIV?
Biological factors
- It’s easier for HIV to be transmitted through unprotected anal sex than through unprotected vaginal sex.
- If a man has another sexually transmitted infection (STI), this can be an extra biological factor that increases his risk of becoming infected with HIV. STIs are relatively common in some communities of MSM, and because men do not always think – or are not always encouraged – to be tested for STIs that are present rectally, these infections often go undiagnosed and untreated. In many cases, fear of discrimination stops MSM from accessing testing services.
Behavioural factors
- Certain behaviours increase MSM’s risk of becoming infected with HIV, such as having multiple sex partners, not using condoms consistently, not learning about HIV or having a complacent or negative attitude towards safer sex.
- Alcohol and drugs are a common part of socialising in some communities of MSM. Drink and drugs can make it more likely that people will have unprotected sex and a higher number of sexual partners. In the U.S. for instance, a study in Los Angeles found that MSM who used the drug crystal meth were three times more likely than non-drug using MSM to be infected with HIV.4
Social/cultural factors
- Some governments and societies are in denial about the fact that sex between men happens, and it is a taboo subject in many cultures. As a result, HIV prevention campaigns often only talk about the risks of heterosexual sex, and there is little appropriate information available to MSM, which can give them the false impression that they are not at risk. There is evidence that this has happened in some Asian countries, for instance.5
- In countries where sex between men is criminalised, MSM are excluded from sexual health services and might find it hard to access condoms and lubricants to protect themselves from HIV.
- A certain proportion of sex between men in most countries is commercial. As with female sex workers, male or transgender sex workers may find it difficult to persuade their clients to use condoms, or may be offered more money to have unprotected sex, increasing the risk that they will become infected with HIV. In some countries there are HIV programmes aimed at female sex workers, but none targeting male sex workers.6
- In countries where antiretroviral drugs are widely available, a climate of optimism about the effectiveness of this treatment may lead some MSM to take more risks.7
Responding to HIV among MSM: the challenges
In the early years of the global AIDS epidemic, it was widely acknowledged that HIV was having a severe impact on MSM in the US and other developed countries where there were visible communities of self-identified gay, lesbian and bisexual people. This led to swift grassroots responses from gay activists, often with support from national governments who realised that carrying out HIV prevention campaigns aimed at gay people was not only the right thing to do on humanitarian grounds, but also something that made sense as a wider public health measure. These early prevention efforts (which included condom promotion and educating men about AIDS) were very successful, and helped to reduce the number of MSM becoming infected with HIV in a number of countries.
In recent years however, the impact of these interventions has leveled off and HIV is becoming common among MSM in many developed countries. It has also become increasingly clear that there is a desperate need for HIV prevention initiatives aimed at MSM in developing regions such as Asia, Latin America and Africa. However, very few countries in these regions are making sufficient (if any) efforts to stem rising rates of HIV among MSM. Globally, fewer than one in twenty MSM have access to appropriate HIV prevention, treatment, care and support services.8
A major reason for this shortcoming is the fact that many countries (87 according to a 2007 report 9) have laws banning same sex relations. Where such laws are in place, governments are unlikely to promote any sort of HIV interventions aimed at MSM. Groups or individuals who do try to carry out such campaigns, as much as MSM themselves, may face violence or arrest:
"The police caught me and hit me. They didn’t even give me a chance to explain... I said I was working for HIV/AIDS prevention. They asked to see my ID card but I had forgotten it that day. They took me to jail. After I promised that I would never go to cruising spots again, they let me go." - HIV prevention worker working with MSM in Bangladesh 10
This kind of discrimination from authorities is sometimes also apparent when MSM who are already living with HIV try to access testing or treatment facilities:
“Our biggest problems are the police and doctors. Many [MSM] people we work with are poor – daily wage-earners – and cannot afford expensive private doctors. When they go to a government health clinic, the doctors taunt them about their sexual preferences. Many prefer to remain untreated rather than suffer discrimination and humiliation." - Christopher Jayakumar, head of the Andhra Pradesh Male Minorities Association, India11
Discrimination such as this stops MSM from revealing their same-sex relations, and may force them to meet potential partners in places that are hidden from the general public. This can make it very difficult to reach them with HIV prevention campaigns.
Experts argue that governments and societies need to adopt a less discriminatory approach if HIV prevention efforts aimed at MSM are to work. This includes repealing laws that criminalise sex between men, introducing laws to reduce human rights violations, and making greater efforts to change public perceptions of MSM. Even in countries where the rights of MSM are legally respected, there is generally a greater need for more commitment towards tackling the problem by donors and governments, as the amount of money put towards campaigns aimed at MSM is often disproportionate to the scale of the problem.
Crucially, more research into the impact of HIV on MSM – particularly in developing countries – would lead to a much greater understanding of the situation and make it much easier to take appropriate action.
"The frightening truth is that, in many parts of the world, we simply do not know how bad the epidemics among MSM groups may be… transmission among MSM is still not tracked in most countries, resulting in a significant research gap. More research is urgently needed to inform more effective HIV prevention efforts.” - Dr. Chris Beyrer, director of the Johns Hopkins Fogarty AIDS International Training and Research Program 12
HIV prevention that works
When MSM are targeted by HIV prevention campaigns, it can be extremely effective. One study of 33 behavioural interventions aimed at MSM around the world showed that these efforts reduced the number of men having unprotected anal sex by one quarter, and increased condom use by 61%.13
One of the most important prevention responses is to make high-quality condoms, along with water-based lubricants, available and accessible to MSM (if suitably strong condoms are not used then they may break, and if oil-based lubricants are used they can damage condoms). In some countries gay bars and other known meeting places for MSM, such as bathhouses, provide and promote condoms and lubricants. Successful prevention work has also been carried out by outreach workers and peer educators, who meet with MSM personally and provide them with condoms, lubricants, and information.
As is the case with sex workers (another marginalised group who are heavily affected by HIV), many of the most successful programmes aimed at MSM empower this group and actively involve them.
"Empowering MSM and other marginalized groups to protect themselves from HIV is one of the world's most urgent health priorities." - Peter Piot, UNAIDS 14
Even in countries where homosexuality is not widely recognised, and where HIV services for gay men are severely lacking, groups of MSM have made a substantial difference in some areas. In India for instance, the use of peers to distribute condoms among MSM has resulted in a significant increase in condom use in the city of Mumbai, where a study found that more than two-thirds of condoms used by MSM were those handed out by peer educators.15
In some countries it has been understood that fighting prejudice and changing public attitudes towards MSM are important prevention measures. In Mexico, the government has appointed Jorge Saavedra, an openly gay, HIV-positive man, as head of its national AIDS council. He has been the driving force behind a large nationwide media campaign to reduce homophobia.16
Another successful approach has been to introduce ‘safe spaces’ where MSM can meet, talk openly and receive sexual health services, including testing facilities and treatment. MSM have specific STI-related needs but often feel uncomfortable going to conventional public sector health services with their problems.17
The internet can be another effective means of reaching out to MSM, as increasing numbers of MSM are meeting online – not just in developed nations, but also in countries such as the Philippines18 and Peru19. Some websites used by MSM place health advisors in chatrooms, display animated characters to educate people about HIV, and encourage users to be open about their HIV-status.20
The way forward
Evidence and experience shows that providing AIDS programmes and services to those who are most at risk can be hugely beneficial to a country’s fight against AIDS. Yet MSM, like other ‘key affected groups’ in the global AIDS epidemic (such as sex workers and injecting drug users) are all too often being neglected by governments and international donors. Stigma and cultural intolerance of same-sex relations are largely to blame for this situation, and until these issues are addressed it will be difficult to make headway in reducing HIV infection levels among MSM – which, in turn, will hinder the wider global fight against AIDS.
"The lack of HIV-related services for MSM] is a massive failure, and setting it right has to be among the highest priorities for the increasingly strong global AIDS response as we aim to achieve universal access to HIV prevention, treatment, care and support for all groups, including men who have sex with men and transgender people." - Purnima Mane, UNAIDS 21
